STP

The Nuffield Trust has published its own research into the credibility of the proposals to shift care into the community, the proposals which underlie Simon Stevens' "Five Year Forward View" (2014) and its implementation in the 44 regional "Sustainability and Transformation Plans" (STPs) (2016).

....• Nonetheless, in the context of long-term trends of rising demand, our analysis suggests that the falls in hospital activity projected in many STPs will be extremely difficult to realise. A significant shift in care will require additional supporting facilities in the community, appropriate workforce and strong analytical capacity. These are frequently lacking and rely heavily on additional investment, which is not available.

.....• While out-of-hospital care may be better for patients, it is not likely to be cheaper for the NHS in the short to medium term – and certainly not within the tight timescales under which the STPs are expected to deliver change. The wider problem remains: more patient-centred, efficient and appropriate models of care require more investment than is likely to be possible given the current funding envelope.

This is a very important and thorough, but brief (16 pages) summary of the problems as at April 2017 by John Lister, head of Health Emergency and Health Campaigns Together, who has monitored the NHS for 30 years.

By way of praise I will borrow the following introduction by Eric Leach, of Ealing Save Our NHS, who edits "Our NHS in Crisis", as follows:

"I have read some excellent pieces of research and writing in the five years I have been trying to make sense of the cost cutting/service change plans for local, regional and national care services.

However one document now stands out in my mind as the most brilliant piece by piece, issue by issue, aspiration by aspiration shredding of the Government’s current plans and supporting evidence for delivering future financial savings and care services’ improvements.

I realise it’s a long read at 16 pages, but I doubt anyone could cover the territory in fewer words/pages. His evidence base is authoritative, comprehensive and wide ranging. No sane person could conclude that there is any credible evidence that implementing the current plans will achieve either of the twin goals of extreme cost cutting and service improvement.

If journalism is "early history" then John has documented in his paper why the STP/FYFV/ACO/Next Steps failed way before 2021".

"The government is 'relaxed' about the crisis in general practice because it thinks Labour can't win the general election, a former GP and health commentator has said.

Former GP Dr Phil Hammond, who covers health policy for Private Eye, said that ministers were ‘very relaxed’ about the NHS because they believe there is no effective opposition.

Plans to create large-scale Accountable Care Organisations to run health and social care services across the NHS would eventually lead to all GPs becoming salaried employees, he added.

Citing a source ‘close to Jeremy Hunt’ Dr Hammond told the annual conference of Londonwide LMCs (Local Medical Committee) on Thursday: ‘They don't believe that Labour is electable. They are very relaxed about the state of the NHS, very relaxed about the queues in casualty, waiting lists going up again, and the disaster in general practice, because they don't believe Labour offers a credible opposition.’

Dr Hammond said the Conservative government viewed the NHS as ‘a service for poorer people’ and wanted those who can afford it to take out private medical insurance.

NHS privatisation

‘They want private companies to do as much NHS work as possible. And they want the NHS to be allowed to do as much private work as it wants to do. That is their ideology and agenda and they don't believe there is an opposition fighting that.’

Dr Hammond, who was one of the first journalists to expose the Bristol babies heart scandal in the 1990s, warned GPs that under NHS England drive towards accountable care systems they could all end up in a salaried service.

The NHS, he said, was ‘keen to move to a model of accountable care organisations where we unify primary, secondary care, social care.’

He added: ‘Ultimately this will make all GPs salaried and working for a large accountable care organisation in a particular area.’

The Conservative Party did not respond to a request for comment".

SOH Comment:

The vast majority of the electorate know nothing about this. It has not been alerted to the detail of Health and Social Care Act 2012 and Simon Stevens' plans from 2014 for co-called "Sustainability and Transformation Plans". The STPs include American-style "Accountable Care Organisations" - the stress is on the word "accountable" or "cost-controlling". They are part of an entirely new and untried, root-and-branch reorganisation of the NHS which the present Government is bringing in very, very quietly.

The NHS will be unrecognisable. The National Health Service will disappear and be replaced by many Regional ("footprint"-based) organisations linking local federations of GPs, local acute services and local government authorities. Each "footprint" organisation (ACO) will have a capped budget - no more deficits, no more overspending. Gone over your budget? No more medical service. The management of the local ACO will devote its energies to finding ways to "deny service". Uninsured and poor Americans know all about this.....

Research paper by Dr Gurjinder Singh Sandhu, published by the Centre for Health and the Public Interest on 19th April 2017. You can read it here (14 pages).

The following graph shows that the closure of Hammersmith and Central Middlesex A&E departments in Sept 2014 caused a very serious decline in the performance of the remaining A&E departments, that they recovered only a little in the summer months and that the trend is downwards.

Dr Sandhu has provided unequivocal evidence using statistics from NHS and other public bodies (Jan 2012- Jan 2017) for the Mansfield Commission findings that SaHF, and by extension the NW London STP, can be shown to fall foul of (1) equalities (BME) legislation and (2) discrimination on grounds of age.

"Conclusions

Since the closure of Emergency Departments in North West London in September 2014, each successive winter has seen deterioration in Type 1 A&E Performance. For some hospitals there has been no recovery over the summer months and emergency care has been in perpetual state of crisis. Ambulance response times are deteriorating, A&E units are unable to offload ambulances, and patients are waiting longer on emergency department trolleys to be assessed, treated and bedded where necessary. For time- sensitive conditions such as sepsis, respiratory failure, kidney failure and the unconscious patient, all this lost time equates to cellular death and eventually patient deaths. A lack of critical care and high dependency unit beds for the sickest patients is the greatest cause for concern.

In North West London A&E closures have also had significant effects on the performance of neighbouring A&E departments. STP footprints are not isolated: the STP for South West London also proposes to downgrade one of five A&Es, which will have a knock-on effect on North West London, and vice versa.

There has been a lack of equality impact assessment on the effects on deprived communities and the elderly in the NW London STP plan. Poverty is shifting from the centre of London to the outskirts, yet across London it is in these areas that clinical networks between a hospital, GPs and social care are being dismantled.

Whilst isolated deaths due to pressures on the emergency system have been reported by the media, disinvestment in NHS and social care services has been explored in one recent study as a factor contributing to nearly 30,000 extra annual deaths in 2015. The authors* expressed significant concerns that a pattern of rising mortality each year is emerging and called for further in-depth scrutiny of what caused this marked increase in mortality. Despite a dangerous deterioration in A&E performance since the closure of two local A&E Departments, the North West London STP still envisages closing a further two A&E units at some point in the future. Future planning needs to learn lessons from the reconfigurations that have already taken place and not continue with A&E closures based on assumptions which have not been borne out in reality."

In early December 2016 Calderdale & Kirklees 999 Call for the NHS posted a summary of 19 Councils’ negative responses to their “footprint” Sustainability and Transformation Plans after the Clinical Commissioning Groups published them following submission to NHS England on October 21st.

Since then Calderdale & Kirklees 999 Call for the NHS has had news of 13 more Councils’ negative responses to their Sustainability and Transformation Plans – which Defend our NHS campaigners have variously dubbed Switch to Private, Slash Trash and Privatise, and Secret Theft Plans.

Simon Stevens, the NHS England Chief Executive, just told the Public Accounts Committee that some Sustainability and Transformation Plans will soon get going as Accountable Care Organisations or systems.

This sounds like more tedious, senseless jargonising.

Indeed one MP, Anne Marie Morris, was so bemused by what Simon Stevens was saying, she asked if they were all smoking dope.

But behind the jargon smokescreen – whether wacky baccy or not - setting up Sustainability and Transformation Plans to run the NHS as Accountable Care Organisations opens up the NHS to privatisation on a bigger scale than anything seen so far.

And it is a mechanism for limiting the range of care that the NHS offers, and for denying care to patients who are judged to offer poor value for money.

This would mean the end of the NHS as a service that provides the full range of health care to anyone who has a clinical need for it.

How does this work?

Sustainability and Transformation Plans require the speedy dismantling of the NHS to turn it into a health service that is based on American private health insurance systems – such as United Health, the former employer of Simon Stevens, now NHS England’s Chief Executive.

Private firms have been paid a ‘shocking’ £2.3m to draw up controversial plans which will cut health and social care spending by more than £1bn in a part of London.

According to health leaders drawing up the North Central London STP (sustainability and transformation plan), six-figure sums were paid to eight different companies – including accountants Deloitte and management consultants McKinsey – for services stretching from ‘administrative support’ and ‘financial modelling’ to ‘communications support’.

A firm called Consultants Methods Advisory Ltd, which describes itself as ‘shaping public services for the digital age’, racked up the biggest costs, invoicing £617,850 for ‘programme management office and strategy support’.

Doctors leaders described the figures as ‘appalling’.

BMA council chair Mark Porter said: ‘While hospitals fall into crisis, social care hits rock bottom and the Government blames hard-working GPs for its political choice to underfund the NHS, every penny of health service money becomes more desperately valuable and doctors will find it galling to see that so much vital resource has been handed to consultancy firms for their part in failing plans which, ultimately, may never come to fruition, while frontline staff struggle to provide safe patient care in a service increasingly becoming unfit for purpose.’

Pick and choose

They came from all over the country united in their concern for the present state of the NHS and their fears for its future. Different sources estimate attendance from "tens of thousands" to 250,000.

From "Save Our Services Cumbria" (Whitehaven Hospital), to "Hands off Huddersfield Royal Infirmary", to "Calderdale 999Call for the NHS" (above), to "Defend our NHS York", to "Bristol Protect our NHS", to "Sussex Defend the NHS", all were protesting about planned or actual A&E, acute units or whole hospitals closures. Health Campaigns Together and the People's Assembly had done a superb job calling together dozens of NHS campaign groups and organizing the biggest NHS demonstration in central London in decades.

For the last two years (since April 2014) NHS England has run a number of experiments (called "Pioneer" programmes), including in NW London, to try to integrate health (hospital) and social care, which is essential for reducing demand for hospital services and is a central part of "Sustainability and Transformation Plans" for the 44 "footprints" of England.

The National Audit Office published its findings on Wednesday 8th Feb. It said: "Integrating the health and social care sectors is a significant challenge in normal times, let alone times when both sectors are under such severe pressure. So far, benefits have fallen far short of plans, despite much effort." "Nearly 20 years of initiatives to join up health and social care by successive governments has not led to system-wide integrated services" "The Departments [of Health and Local Government] have not yet established a robust evidence base to show that integration leads to better outcomes for patients" and finally "There is no compelling evidence to show that integration in England leads to sustainable financial savings or reduced hospital activity".

Trying to mix health and social care is like trying to mix oil and water, due to the different funding and cultures.

When NHSE, an executive body of the Dept of Health, publishes information, especially as a result of a Freedom of Information request, the public has a right to be able to rely on its contents.

But in the question and answer session Christian Cubbitt, Director of Communications for NHS NW London Collaboration of CCGs, publicly retracted the figures. He said that they were "incorrect" and that there would not be nearly 8,000 job losses. He said that the "correct" figures would be produced, but did not give any deadline.

Given that the objective of the STP is to find £1.3Bn of savings and that the template of the STP is set by the Dept of Health, it is impossible that the final numbers will be very different from the ones just published, using the same categories. SOH and its advisers have looked closely at all the pages in the workbook, including the "solutions" which are the balancing figures between the "Do Nothing" and the "Do Something" scenarios. Most of the solutions include words like "these costs have not been finalised". For Solution 4 (NHSE Specialised Commissioning) it says: "We have not yet developed the "solution" for closing the gap, however it is assumed that this gap will be closed. This is a placeholder".

The Delivery Plan is obviously nearly right too.

The denial by NW London CCGs is a clumsy attempt to limit the harm after the release of highly damaging information which should not have been disclosed on the grounds that its release would prejudice incomplete development of the plans. But then the FOI request would probably have been forwarded to the Information Commissioner and SOH would have made a big fuss about the refusal and about the fact that the figures were still being worked on three months after submission to NHSE on 21st October as a "final" version.

That is why the current dispute about the status of the information produced by the NHS's NW London Collaboration of Clinical Commissioning Groups reveals even more than the figures themselves.

The rising pressures on Imperial College Healthcare NHS Trust finally took their toll yesterday. Dr Tracey Batten, CEO of the trust with three of the busiest acute hospitals in west London, resigned after the Board meeting in public at Charing Cross yesterday, Wednesday 25th January 2017.

The timing of this resignation could not be worse, with A&E attendances rising to unmanageable levels, a growing waiting list for surgery both emergency and elective, and a programme of redevelopment at a critical point at St Mary's and in the wider context of the "Shaping a Healthier Future" business plans.

Dr Batten was brave and honest to allow the BBC full access to Imperial's hospitals over 6 weeks. The documentary series "Hospital" is being broadcast on BBC2 on Wednesdays at 9pm, available later on the i-player.

The Trust is closely helped by PwC for day-to-day financial management, although we were assured at the Board meeting on Wednesday that it "can pay its bills".

NW London is one of the 44 NHS "footprints" in the most advanced stages of preparation for the implementation of its "Sustainability and Transformation Plan". It is known to be closely watched by the Department of Health. The pressure of implementing completely unwarranted and impossible cuts has, it is believed, prompted this resignation. We look forward to Imperial acknowledging that the evidence shows increased demand for beds, not for cuts in beds and staff.

Postscript: On 6th February Dr Batten informed us that in 6 months she will be going back to spend time with her ageing parents in Australia.

STPs must “encourage” long term NHS “partnerships” with the private sector

Since the Autumn 2015 Comprehensive Spending Review that created the Sustainability and Transformation Fund, both the government and NHS England have explicitly linked the Sustainability and Transformation Plans to the requirement to “encourage” increased private sector involvement in the NHS.

Some key aspects of STPs’ mandatory “encouragement” of long term NHS “partnerships” with the private sector include

Strategic partnerships with the NHS and the 39 Local Economic Partnerships.

The abandonment of “old-style contracting” and the imposition of private company-friendly contracting.

Embedding digital technology in STPs.

Strategic partnerships with the NHS and the 39 Local Economic Partnerships

This aspect of Sustainability and Transformation Plans seems to be enthusiastically driven by the NHS Confederation – the trade association for private health companies with NHS contracts.

It involves increased privatisation and public/private partnerships between a vast range of NHS commissioners and providers, private health companies, voluntary and community sector organisations and a range of other companies, as health and social care services are harnessed to Local Economic Partnerships as a vehicle of economic growth and a way of securing “external investment” in the NHS through “a host of new finance mechanisms”.

According to the NHS Confederation, which describes itself as a network of NHS “partners” – i.e. private companies – the aim is to “match fund” NHS England’s 5 Year Forward View – the plan behind the STPs.

This is staggering. They are talking about £hundreds of billions of private sector money coming into the NHS so it will no longer be a publicly funded, owned and managed health service.

This is ALL being done by stealth.

This move is supported – again by stealth – by a recent outrageous letter from NHS Providers – the trade association of NHS Trusts & Foundation Trusts – to The House of Commons Select Committee. The letter called for an inquiry that will change the NHS policy framework to bring it in line with STP – driven withdrawal and/or restrictions of a variety of treatments.

The NHS Providers say this is being done in contravention of the current NHS policy framework of a comprehensive service that is free at the point of clinical need for all patients that have a clinical need for it.

NHS Providers are asking for an inquiry that will recommend policy changes that will effectively end the NHS and turn it into a brand for a public/private partnership operating along the lines of the US health digitech and insurance companies – Cerner and United Health, respectively – that previously employed NHS England head honchos Mathew Swindells and Simon Stevens.

The abandonment of “old-style contracting” and the imposition of Cerner and United Health-friendly contracting

Matthew Swindells recently told Clinical Commissioning Groups to abandon “old style” contracting . What will replace the “old style” contracting – the current system of commissioning and providing NHS and social care services – is Accountable Care Organisations (ACOs).

ACOs are a form of public-private partnership. Think Private Finance Initiative, but for NHS services as well as buildings. The hot favourite ACO model – plugged by the pro-privatisation think tank the Kings Fund in a health system redisorganisation “masterclass” on 12 October – is South Central Alaska.

Cerner is behind the Kings Fund’s promotion of South Central Alaska ACO as the new STP form of contracting. The company commissioned the Kings Fund report that plugs the South Central Alaska ACO, with the brief to:

“write a report analysing how an intentional whole health system redesign can deliver better health outcomes to a population. The report, based on independent research conducted by The King’s Fund, focuses on Southcentral Foundation”

Delivering better health outcomes to a population sounds like a good goal.

There are just two problems.

There seems to be no reliable evidence that this model of ‘integrating care’ will reduce costs or improve patients’ health.

And there seems to be little faith that it can actually be delivered on the ground. Dr Robert Morley, the Chief Executive of Birmingham GPs’ Local Medical Committee saysthis model of care is ‘simply undeliverable’:

‘The STP, and in particular the plans to massively increase the delivery of out-of-hospital care, to transform general practice and to give it far greater responsibilities across a range of areas are simply undeliverable bearing in mind the meagre additional investment, the unambitious plans to increase primary care workforce and the woefully inadequate intention to support general practice sustainability and viability.’

So what is driving these ideas? And what are they really designed to achieve?

Clues leak out in the STPs – and earlier documents like Calderdale and Greater Huddersfield’s “Right Care Right Place Right Time” NHS and social care reconfiguration documents and the 2014 Better Care Fund Submission from Calderdale Council and Calderdale Clinical Commissioning Group.

These proposals will ‘create a responsive local market’ for health and social care. They will also ‘reduce the pay bill’ and make increased use of patients’ self management as well as “business-ready” voluntary sector organisations in the new “locality-based” integrated teams. These are themselves likely to be privatised – with tax avoiding Virgin Care are a contentious front runner that has just mopped up a £700m contract to run Health and Adults Social Care in Bath and NE Somerset.

The STPs’ “new models of care” are all dependent on a hugely increased use of health digital technology. Health information systems apparently will deliver a $53 billion market globally in 2019 because of vaguely defined proposals for ‘integrated care’ and ‘care closer to home’. Good news for marketeers, bad news for patients and NHS staff .

This is the route to turning patients into consumers, who dispose of a mix of NHS personal health budgets and – if they can afford it – top ups paid for out of their own purse. So, it is the route to a two tier NHS – like the already totally marketised two tier social care system. And the money the patients/consumers spend goes directly to digitech companies like Cerner.

This is at the say-so of Matthew Swindells, previously Vice President of US health digitech company Cerner, now NHSE National Director for Commissioning Operations and Information

At the September 2016 NHS Expo– a business-sponsored event plugging the wonders of privatisation via personal health budgets and a bonanza for big pharma and big digitech – Matthew Swindells announced that digital technology must be embedded in Sustainability and Transformation Plans.

New STP Digital excellence centres – also announced at NHS Expo – promote patients’ use of smartphones and mobile devices. The Acute Trusts that are centres of digital excellence will set up digital technology so that patients can access more services via smartphones and mobile devices.

This ties in with the so-called Care Closer to Home scheme that copies the model for “demand management” used by the American private health care company, Kaiser Permanente.

It requires patients with long term health problems to monitor their own symptoms at home using interactive digital technology that will send data about their bodily processes to specialist nurses and/or GPs.

The aim is to target care without relying on expensive personal contact between doctors/nurses and patients as a way of checking on patients’ health.

The system would also direct behaviour change incentives and messages to people statistically at risk of developing various illnesses. This aims to reduce the likelihood that they will become ill.

But there’s little evidence that this actually works.

And it looks as if a lot of the much-vaunted increase in NHS funding via the Sustainability and Transformation Fund, is going straight into the pockets of digitech companies like Matthew Swindell’s former employer.

Here is what Cerner has to say about the kind of health digitech that the £100M Digital Excellence Fund is going to pay for:

“Cerner has several exciting projects and relationships related to some key aggregation platforms, including Apple and Validic, which are on the augmented self-management end of the remote monitoring spectrum, and Qualcomm Life, which is active monitoring. Cerner also has a relationship with Livongo to improve outcomes for diabetics. These relationships will increase the ability for Cerner clients to track their patients remotely, whether to manage chronic conditions through a prescribed device or kit, or through an ecosystem of apps enabling patients to manage their day-to-day health.”

The NHS England panel that chose which Trusts to award the centres of digital excellence funds to was apparently led by Professor Keith McNeil, NHS England’s first chief clinical information officer, who reports to Matthew Swindells.

And Simon Stevens had previously announced at the 2016 NHS Confederation conference that:

“…from April next year, we will add a piece to the national tariff system specifically for new med tech innovations that have been shown to be cost-saving or help patients with supported self-management.”

This sounds a lot like a repeat of Tony Blair’s NHS Programme for IT (NHSPfiT), which pretty much ended in tears. Is the STP Digital Excellence scheme going to do any better? And will it even matter to the revolving door merchants Simon Stevens and Matthew Swindells, who are pushing it? After all, as Stuart Player and Colin Leys wrotein 2010 :

“…the plan to turn the National Health Service into a healthcare market does not rest on rational arguments but material interests… the plans are not really new, but are the culmination of a decade-long campaign by the private health industry to get its hands on the NHS budget.”

And that is what the STPs are really about: cuts, privatisation, and a paradoxical central control over “devolved”, fragmented public/private NHS and social care.

Four hundred people came to Hammersmith Town Hall on a cold Tuesday night (29th November) to hear about the fight against NHS proposals which will force the closure of Ealing and Charing Cross Hospitals.

Health services in the north west of London are already stretched after "Shaping a Healthier Future" (SaHF) plans (2012) resulted in the closure of Hammersmith and Central Middlesex Hospitals’ A&E departments in September 2014. Ealing lost its maternity unit in 2015 and its children's ward last June.

In June 2016 local authorities in England were being asked to sign up to Sustainability and Transformation Plans ("STPs") but Ealing and Hammersmith and Fulham Councils have refused to do so, saying that this would see the end of their hospitals as major providers of vitally needed blue-light A&Es and acute beds.

The meeting was chaired by Hammersmith and Fulham Council’s Vivienne Lukey, cabinet member for health and adult social care.

Professor Ham, thank you for your detailed, but much understated piece - notwithstanding the statement about STPs that..... 'they are attempting to undertake synchronised swimming against a rip tide'!

The reality is that the current plans and timescales being imposed on STPs are reckless and dangerous. There should be an IMMEDIATE MORATORIUM called on STPs and other similar major re-organisations of the NHS that are in the pipeline.

STPs may well be fine in theory - and that is debatable - but as you clearly state they are not a short-term answer to austerity and quickly delivered savings. In their current incarnation - with the expectation of immediate savings and transformation occurring in a fraction of a financial year they are a reckless and dangerous absurdity. The only sane solution is a moratorium. The NHS and its funding need a proper overall review with some bridging funding made available to meet the immediate needs of the NHS deficit and a proper cross-party/stakeholder consultation to decide its future.

The need for the Acute sector cannot be 'wished away' as you make clear in your piece. I suspect that a lot of recent health policy has been made by fantasists in denial that acute illness really exists. The acute sector has been mistakenly marginalized since - at least - the introduction of the fatal Lansley 'Health and Social Care Act' and the Darzi report.

It will take years of coordinated planning and investment to get prevention and social care to the point where they can make a real impact on hospital activity and the more acute and severe manifestations of ill-health. This certainly will not happen while the current mania for major uncoordinated and unfunded interventions is indulged by the detached and unaccountable elites currently making health policy.

The leadership and vision that the NHS needs is completely lacking from the Secretary of State for Health, the DoH and NHS England - otherwise why would any serious health policy makers be endorsing the unsightly haste with which STPs are being pushed forward? It is a dangerous collective delusion in the context of an engineered funding crisis, collapse of workforce morale, years of austerity cuts and an arrogant policy-making elite who have no interest or respect for 'evidence', 'piloting' or consultation. I have to try and hope that many of them are likely to be well meaning, but many others seem to have serious problems with the original 'mission' and aims of the NHS and are impatient and opportunist in their desire to re-fashion it into something that I believe the great majority of the population that the NHS serves would find very disturbing.

In summary, I believe that there needs to be an immediate moratorium on STPs and other major NHS re-organization, including the increasing role of the private sector. Bridging funds need to be made available to consolidate safe healthcare in the short-term while these issues are being sorted out to mitigate the impact of the current chaos.

The debate will need to start with a public debate about the amount spent on health in the UK as a proportion of GDP, in order to ensure that 'affordability' for the NHS is decided by the population at large with a clear view of the wider political and other factors and choices that help to define 'affordability' and the 'limited' funding for the NHS.

The King's Fund and the Nuffield Trust have already provided sufficient dispassionate and well-researched data and analysis to inform many of these issues and help start the process. However, unless the brakes are put on the current inchoate jumble of proposals and policies, the impact on the NHS and the nation's health will take years to unravel and will be the cause of much unnecessary human suffering.

Sincerely yours,

Dr Christopher Wood (with over 30 years service in the NHS, nearly 20 of those as a Hospital Consultant)

His Honour Peter Latham is Chair of Willesden Locality PPG and a member of the CCG EDEN Committee. He is a retired barrister with a specialist medico/legal practice and a retired Circuit Judge who sat at central and north London county courts including Willesden. He has lived in and been an NHS GP patient in Willesden for over 45 years.

1. Patients and public cannot reach conclusions about the overall merits of the NHSE Five Year Forward View NW London STP because the draft dated 30 June 2016 appears to be deliberately obscure and incomplete about key details: either because they have not yet been formulated, or to make public opposition difficult during the transformation. The main NHS Project Initiation Document (PID), the Business Case, Management Consultants' reports and other key documents have not been disclosed even to the small number of 'lay partner' patient representatives hand-picked to attend some NW London Collaboration of CCGs meetings.

2. From a patient perspective from the time the NHS Act 1946 came into force on 5 July 1948 the model has changed remarkably little. Most NHS medical care is still obtained by visiting your GP who will refer you to hospital for specialist investigation and treatment when required. Most of the GP practices remain the same, and the hospitals mostly remain the same. Social care has been provided separately by the local council. The multiple NHS administrative shake-ups of Health Authorities etc. have barely been noticed by patients including the Health and Social Care 2012 Act's introduction of CCGs. The STP proposes the most radical changes to this structure since 1948 that appear to introduce a model that most GP's and almost all patients still do not understand and are mostly unaware of.

3. The NHS Five Year Forward View and STP projects are major 'top down' policies that are clearly mostly focussed on reducing NHS costs to keep within a Government cost cap fixed by HM Treasury. It is an old joke that is funny because of its element of truth that the NHS is the last great Stalinist institution in Europe. The UK allocates about 9% of its GDP on the NHS where other developed counties obtain better outcomes as measured by survival rates for serious conditions on allocating about 11 % of GDP to healthcare. It is arguable that this is really the main problem.

4. In seeking to transfer so much healthcare out of hospital into community services the NHSE Five Year Forward View and the STPs are swimming against the international tide of healthcare improvements obtained with new sophisticated investigations and treatments provided by increased hospital doctor specialisation. In 1948 hospital Consultants were mostly general surgeons and general physicians. Initially antibiotics delivered the great improvement in medical care. All over the world the secondary hospital landscape has changed out all recognition since 1948 with increased medical and surgical specialisation and sub-specialisation for both investigations and treatment. Granted, many special investigations such as resting ECG can now be carried out by the new generation of hospital trained GPs with machines that have become much smaller and cheaper. Many routine low-tech mass numbers hospital services such as diabetic clinics can be transferred out of of hospital to be provided in the community. It remains to be seen whether they will prove to be cheaper and more efficient. But it appears that the STP attempts to swing the pendulum too far.

5. It is not clear what will happen to the traditional GP family doctor practice model under the STP. It has become fashionable amongst NHE executives and their business consultants to decry them as a 'cottage industry'. The core of structural change is the new Multi-speciality Community Provider (MCP) contract for over-arching primary care with 'intermediate' out-of hospital and new primary services provided at 'hubs' leading on to full Accountable Care Partnerships (ACP) by 2021. It is said that primary care will be delivered through networks, federations of practices, or super-practices working with partners. The NHS England publication 'Multi-specialty community provider (MCP) emerging care model and contract framework' published July 2016 at page 30 says:

”New models of accountable care provision will move the boundary between what is commissioning and what is provision. We are working with a number of MCP vanguards to establish which activities must always remain with the CCG (or other commissioners), and which activities an MCP would perform under contract.”

6. No detail is provided of how MCPs and ACPs will work - or how they will affect the traditional NHS GP practice delivered by SMS and APMS contracts. No experience from any existing whole population state-funded model is identified. The King's Fund March 2014 paper on Accountable Care Organisations in the US and England pointed out that the US models on which this concept is based are all much smaller and with different sources of funding. It is arguable that the STP disregards the excellent value for that we obtain from our traditional GP practices - for all their faults – for about 9% of the total NHS budget. It appears that in these new over-arching structures the traditional SMS GP contract may be left to wither on the vine by re-allocating funding to make them unviable. It is arguable that a better, more achievable, and more cost effective solution could be obtained by simply putting more resources into the existing GP network. If the current STP is implemented in full it seems likely that in 10 years time the pendulum will swing again back on a new slogan 'Small is beautiful'.

7. The STP integrated medical and social care proposals depend heavily on the individual patient information sharing duties in the Health and Social Care (Safety and Quality) Act 2015. NW London and Brent CCG posters have have already been put up in Brent GP practices. No date is stated for the start of the sharing, nor exactly what will be shared, nor with whom. The section on Integrated Care Record says:

"The Integrated Care Record (ICR) will display a range of test results, medication, allergies and social or mental health information relevant to the care of that person. Information around people's cost of care may also be included as part of the ICR. It is expected that this will be a key enabler in improving decision making when determining people's care needs."

The last sentence is disingenuous. When it speaks of 'care needs' it clearly does not mean investigation and treatment 'needs': it means cost-controlled investigation and treatment 'allocation'. Under the heading Service User Consent the poster says that "people are able to opt out of their information being shared at any point...." and goes on to claim that if you decide to opt out later the ICR will be re-created. We can find nothing in legislation that authorises this 'opt-out' model of purported implied consent by default. This appears to be an attempt to re-introduce the opt-out model on which the 'Care.data' failed. Doctors' misgivings about this 'opt-out' model are revealed by Brent CCG providing them with an indemnity against claims for breach of their doctor-patient duty of confidentiality, and penalties under the Data Protection Act 1998. But the indemnity will not protect them against strengthened criminal responsibility under this Act. Nor will it protect them on misconduct complaints to the GMC disciplinary committee for breach of their common law duty of patient confidentiality.

8. An important under-pinning for the financial viability of the STP's ACP and MCP model is the choke being introduced on GP clinical independence on hospital referrals and patient choice. The new Brent Referrals Optimisation Service that started on 1 September 2016 attempts to impose a CCG-supervised clinical triage service through its provider Bexley Health Limited on all NHS GP patient referrals designed to steer all patients into cheaper relevant out-of-hospital community healthcare services where available. The patient information letters produced for this service do not inform patients about their NHS statutory and NHS contractual patient choice rights, and Brent CCG have rejected public consultation proposals that they be inserted. Without this under-pinning the CCG will not be able to assure providers that they will reliably deliver enough patients for their services to be viable financially.

9. There are very big risks with pushing ahead so fast with such a big programme of new models that are as yet untried and untested, since the few Vanguard pilots have only recently started. It is arguably reckless to put so much into new models that have foreseeable but unquantifiable risks of financial insolvency and bankruptcy liquidations when all the responsibility would fall back onto the NHS for expensive crisis management. It appears unrealistic to think that the whole NW London Collaboration STP project can be delivered by 2020/21. Its parallel Shaping a Healthier Future programme (SaHF) became stalled when the capital costs of about £1 billion required to deliver it became clear. When Brent CCG, on commencing in 2014, tried to develop an ambitious Planned Care project for about 13 medical speciality 'out of hospital' community services this project also stalled on attempting to introduce an integrated multi-disciplinary MSK (musculo-skeletal) service as the third of the new services. Both these big projects have remained stalled.

10. The STP proposes to transfer a large part of hospital care into community services commissioned by the CCGs through the new vehicle of one of the variants of the new Accountable Care Provider (ACP) models by the new Multi-speciality Community Provider (MCP) contract model. This appears to seriously weaken the statutory CCG governance model of the Health and Social Care Act 2016 just by administrative action without fresh statutory approval. The 2012 Act created major conflict of interest problems with GP members of the local CCG involved in providers tendering for contracts from the CCG. This conflict of interest is likely to be greatly increased with GPs encouraged by the STP to form large ACP-variant healthcare providers to tender for £multi-million community healthcare contracts from themselves wearing their CCG hats. Large public money scandals are predictable.

11. It appears that there are major financial implications of the STP move to ACP and MCP that have not been disclosed. Why go to all the trouble of setting up the Accountable Care Partnership (ACP) and Multi-speciality Community Provider (MCP) structures ? It now appears that again this may be largely about an attempt to get big future financial liabilities for pensions and clinical negligence off the NHS books. All large employers are desperately seeking advice from lawyers and management consultants on how to do these things. It seems that the NHS now wants to do hat Sir Philip Green did for BHS pensions. Similarly with clinical negligence liability. The NHS clinical negligence compensation bill in 2015 was about £4 billion - up £1 billion on the previous year. It is very difficult to investigate these queries through the obscure finance sections of the NW London Collaboration draft STP dated 30 June 2016. It was the same story with the ill-fated PFI initiatives. When such liabilities are transferred to new contractors they inevitably have to increase their tender figure and add a safety margin. It is foreseeable that commercial professional liability insurers will quote very high premiums to cover such alarge and fast growing contingent liabilities.

12. A great deal of the projected cost savings of the STP are highly suspect as unreliable and unrealistic. Many of the cost savings are projected from progammes to reduce long-lasting and increasing obstinately intractable conditions such as obesity and Type ll diabetes, and from preventive medicine projects. The results of the NHS accounting formulae for booking such projected savings are highly speculative. You can insert almost any figure you wish.

13. The problems of rushing through such large structural changes are likely to be aggravated by the increasing loss of confidence of the clinical workforce: as evidenced by the current industrial action by the junior doctors. For 68 years the NHS has traded on exploiting the vocational commitment of its doctors. The NHS appears to be losing much of this goodwill.

14. On 12 September 2016 the King's Fund Chief Executive Chris Ham published a commentary with muted criticism of what has been published to date about the STPs including his analysis that the ACP and MCP model is swimming against the statutory set-up tide of the Health and Social Care Act 2012 with CCGs of local GPs made responsible for promoting competition within the NHS healthcare economy - http://www.kingsfund.org.uk/blog/2016/09/stp-leaders-challenges-care-budgets?utm_source=linkedin&utm_medium=social&utm_term=thekingsfund.

15. It is very unfortunate that there is so little informed public scrutiny of the STP. Because the changes are being introduced entirely by administrative action there have been none of the automatic debates in Parliament and committee scrutiny that would accompany primary legislation. The BMA and doctors' Royal Colleges have remained strangely silent about the STP. There is just no equivalent of academic and expert peer-review scrutiny. It is being left to a very few concerned individuals to provide devil's advocate scrutiny of the proposals from the limited and late information released, and to identify weaknesses and to voice public concern. In the fable it was only the naive little boy who dared contradict the court conspiracy of silence and speak out saying that the Emperor had no clothes.

16. A major criticism of the NW London STP process is the failure to publish enough of the plans to enable the public to understand the radical changes afoot for delivery of NHS primary care. In the last analysis the default to be criticised is that by the local Clinical Commissioning Groups. Under section 14Z2 of the National Health Service Act 2006 (as amended by section 26 of the Health and Social Care Act 2012) the statutory duty remains with the CCG to involve and consult its patients and public in the planning of its commissioning arrangements and in the development and consideration of its proposals for changes in its commissioning arrangements where they would have an impact on the manner or in the range of health services available to them.

The man overseeing a radical plan to ward off a funding crisis in north London’s health services has said a solution has “not yet been found”. David Stout, director of the "North Central London Sustainability and Transformation Plan" (STP), today told Islington councillors – along with others from Camden, Haringey, Barnet and Enfield – that he did not know how to ward off an impending £876 million health budget deficit.

Ministers have been urged to sort out the ‘mess’ of the NHS STPs (sustainability and transformation plans) after BMA analysis found they must slash £22bn from health and social care costs in five years.

The savings figures were found in papers from 42 of the 44 areas across England.

Officials in each area have been asked by NHS England to predict the financial holes STPs face in their budgets in 2021 and set out how they can close them.

A separate survey by the BMA reveals that most doctors (64 per cent) had not been consulted on STPs, despite many plans requiring significant changes to services to balance their books.

BMA council chair Dr Mark Porter said he had serious concerns about the ‘impossible’ scale of savings demanded by STPs by an ‘unrealistic Government’ which had promised no further funding.

Royal College of Surgeons calls for rethink after figures show 89% of beds are full overnight for fourth quarter in a row

The Royal College of Surgeons has warned of a chronic shortage of NHS hospital beds in England, after occupancy rates for overnight stays topped 89% for a fourth successive quarter.

The maximum occupancy rate for ensuring patients are well looked after and not exposed to health risks is considered to be 85%, a figure that has not been achieved since NHS England began publishing statistics in 2010.

From July to September this year the percentage of beds occupied in wards open overnight was 89.1%, compared with 87% in the same period last year. That was the last time it was below 89%.

More than half of doctors in London have not heard of sustainability and transformation plans (STPs) due to be published by the end of this year, a BMA survey shows.

Of the 615 consultants and GPs surveyed, a majority (59 per cent) said they had not heard of STPs - five year plans detailing how areas will work together to implement NHS England’s Five Year Forward View.

The BMA asked GPs and consultants in London about their involvement in the creation of the four STPs footprints for the city, made up of clinical commissioning groups (CCGs), local authorities, NHS trusts and other health and care organisations.

When asked if doctors felt they could influence decisions made by their clinical commissioning group (CCG), more than four in five (82 per cent) said they did not feel they could, even though CCGs are membership organisations.

The plan involves a complete upheaval of every service, from community care to mental health services to GPs to A&E departments to acute beds in the major hospitals, in NW London. The central aim of the plan is, we are told, to save money: a staggering £1.3 billion over the period to April 2021.

Hammersmith and Fulham Council strongly opposes the STP and has voiced its opposition to the NHS bodies concerned.

By offering additional funding for NHS commissioners who satisfactorily reduce their deficits and by threatening punitive “special measures” for those who don’t, the STPs will serve private sector interests. NHS cuts to reduce deficits will mean the NHS, and the public, having to seek more services from the private sector. More public money will benefit private companies whose services cost far more than a publicly funded, publicly run NHS. Less accessible services and longer waiting times will push the public to pay for private health insurance.

Babbs omits to mention US influence in NHS restructuring, which Jeremy Hunt has acknowledged. Major US consultancies and healthcare corporations like McKinsey and UnitedHealth are heavily involved. But he confirms that 38 Degrees commissioned Incisive Health, lobbyists for Virgin Healthcare and the privatisers’ NHS Partners Network, to produce its crowdfunded report. It’s not surprising it glosses over what the STPs prefigure – the replacement of an NHS once recognised as world leading in cost-effective public healthcare by a privatised system whose providers’ financial interests will have undue sway. As members of 38 Degrees, we think it’s vital that it isn’t seen as an NHS privatisers’ tool.

The government's Sustainability & Transformation Plans (STP) have been shrouded in secrecy. Despite being the biggest change to the NHS since the Health & Social Care Act 2012, they will not be voted on in parliament.

So what exactly are the STPs? The NHS will be divided up into 44 footprints, but you need a glossary to translate these terms. Sustainability means cuts. This is part of the drive towards £22bn in cuts by 2020 – bearing in mind that we've already had £15bn in NHS cuts in the last parliament generating a manufactured crisis. Cuts mean a massive programme of hospital closures across the country and it will also lead to mergers and permanently selling off the NHS estate of land and assets.

The bogus narrative around unsustainability and unaffordability has been spun by the private healthcare and insurance industry, captured politicians and the media. In truth, we spend much less on healthcare than other advanced economies.

In order for these footprints to receive funds, there are strings attached. The footprints will have to sign up to transformation, which basically means privatisation. The footprints will have to adopt unproven models of care.

The bigger picture here is integrated healthcare. It sounds great but it's imported from the US. The NHS five year plan – the Five Year Forward View – specifically states that the NHS should emulate US style integrated or accountable care. Integrated care organisations are springing up all over the place.

This is all being sold as care in the community, but there are no extra resources for GP and community services.

The current STP is the Oct 2016 version. In January 2017 the finance spreadsheets and the Delivery Plan were obtained by FOI. They reveal job cuts of 8,000, outpatients cuts of 222K, planned admissions cuts of 50K and A&E admissions cuts of 64K cumulatively by 2020/21. 500-600 beds will be cut by end March 2021.

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